STIKES RS BAPTIS KEDIRI

PRODI PENDIDIKAN PROFESI NERS PROGRAM PROFESI

FORMAT ASUHAN KEPERAWATAN DASAR PROFESI

NAMA MAHASISWA : ..................................................................................

NIM : ..................................................................................
RUANG : ..................................................................................
TANGGAL : ..................................................................................

1. BIODATA
Nama Pasien : ..............................................................................................
Nama Panggilan : ..............................................................................................
Umur : ..............................................................................................
Status : ..............................................................................................
Agama : ..............................................................................................
Pendidikan : ..............................................................................................
Pekerjaan : ..............................................................................................
Penghasilan : ..............................................................................................
Alamat : ..............................................................................................
Diagnosa Medis : ..............................................................................................
Tanggal MRS : ..............................................................................................
Tanggal Pengkajian: .............................................................................................
Golongan Darah : ..............................................................................................

2. KELUHAN UTAMA
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3. RIWAYAT PENYAKIT SEKARANG

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4. RIWAYAT PENYAKIT MASA LALU

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5. RIWAYAT KESEHATAN KELUARGA

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GENOGRAM :

6. TANDA – TANDA VITAL

Suhu Tubuh : ....................................... oC
Denyut Nadi : ....................................... x / mnt
Tekanan Darah : ....................................... mmHg
Pernafasan : ....................................... x / mnt
TT / TB : ....................................... Kg, ....................................... cm

7. POLA AKTIVITAS SEHARI – HARI

a. Kebutuhan Kebersihan Diri / Personal Hygiene

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b. Kebutuhan Nutrisi / Pola Nutrisi
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c. Kebutuhan Eliminasi / Pola Eliminasi BAK, BAB
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d. Kebutuhan Oksigenasi
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e. Kebutuhan Cairan dan Elektrolit
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f. Kebutuhan Aktivitas
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g. Kebutuhan Rasa Aman dan Nyaman
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h. Kebutuhan Psikososial dan Spiritual
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8. KEADAAN / PENAMPILAN UMUM PASIEN

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9. PEMERIKSAAN FISIK

a. Pemeriksaan Leher dan Kepala

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b. Pemeriksaan Integumen
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c. Pemeriksaan Payudara dan Ketiak
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d. Pemeriksaan Dada / Thorak
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e. Pemeriksaan Jantung
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f. Pemeriksaan Abdomen
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g. Pemeriksaan Genetalia dan sekitarnya

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h. Pemeriksaan Muskuloskeletal
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i. Pemeriksaan Neurologi
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j. Pemeriksaan Status Mental

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10. PEMERIKSAAN PENUNJANG MEDIS

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11. PELAKSANAAN / TERAPI

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12. HARAPAN KLIEN / KELUARGA SEHUBUNGAN DENGAN PENYAKIT

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 ANALISA DATA

NAMA PASIEN :
UMUR :
NO. REGISTER :

DATA OBYEKTIF (DO) FAKTOR YANG MASALAH KEPERAWATAN

DATA SUBYEKTIF (DS) BERHUBUNGAN/RISIKO (P)
(E)

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 DAFTAR DIAGNOSA KEPERAWATAN

NAMA PASIEN :
UMUR :
NO. REGISTER :

NO TANGGAL DIAGNOSA TANGGAL TANDA

MUNCUL KEPERAWATAN TERATASI TANGAN
(SDKI)

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 RENCANA ASUHAN KEPERAWATAN

NAMA PASIEN :
UMUR :
NO REGISTER :

DIAGNOSA KEPERAWATAN :

1. SIKI :
a. Dipertahankan/ditingkatkan pada
b. Dipertahankan/ditingkatkan pada
c. Dipertahankan/ditingkatkan pada
d. Dipertahankan/ditingkatkan pada
e. Dipertahankan/ditingkatkan pada
f. Dipertahankan/ditingkatkan pada
g. Dipertahankan/ditingkatkan pada
h. Dipertahankan/ditingkatkan pada
i. Dipertahankan/ditingkatkan pada
j. Dipertahankan/ditingkatkan pada
k. Dipertahankan/ditingkatkan pada

2. SIKI :
a. Dipertahankan/ditingkatkan pada
b. Dipertahankan/ditingkatkan pada
c. Dipertahankan/ditingkatkan pada

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 d. Dipertahankan/ditingkatkan pada
e. Dipertahankan/ditingkatkan pada
f. Dipertahankan/ditingkatkan pada
g. Dipertahankan/ditingkatkan pada
h. Dipertahankan/ditingkatkan pada
i. Dipertahankan/ditingkatkan pada
j. Dipertahankan/ditingkatkan pada
k. Dipertahankan/ditingkatkan pada

3. SIKI :
a. Dipertahankan/ditingkatkan pada
b. Dipertahankan/ditingkatkan pada
c. Dipertahankan/ditingkatkan pada
d. Dipertahankan/ditingkatkan pada
e. Dipertahankan/ditingkatkan pada
f. Dipertahankan/ditingkatkan pada
g. Dipertahankan/ditingkatkan pada
h. Dipertahankan/ditingkatkan pada
i. Dipertahankan/ditingkatkan pada
j. Dipertahankan/ditingkatkan pada
k. Dipertahankan/ditingkatkan pada

Keterangan : (dipertahankan/ditingkatkan) coret salah satu

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 RENCANA ASUHAN KEPERAWATAN

NAMA PASIEN :
UMUR :
NO. REGISTER :

NO DIAGNOSA INTERVENSI RASIONAL

KEPERAWATAN (SIKI)

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 TINDAKAN KEPERAWATAN

NAMA PASIEN :
UMUR :
NO.REGISTER :

NO NO.DX TGL/JAM TINDAKAN KEPERAWATAN TANDA

TANGAN

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 CATATAN PERKEMBANGAN

NAMA PASIEN :
UMUR :
NO.REGISTER :
NO NO DX JAM EVALUASI TTD

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 DAFTAR PUSTAKA

1. Amelia K., Hanny H. (2005). Buku Panduan Keterampilan Dasar Profesi Keperawatan.
Fakultas Ilmu Keperawatan UI. Jakarta: Penerbit Fakultas Ekonomi UI.
2. Harkreader, H., Hogan M.A., Thobaben M. (2007). Fundamentals of Nursing Caring and
Clinical Judgement. Canada: Elsevier.
3. Kozier, B., Erb, G., Berwan, A.J., & Burke,K. (2008). Fundamentals of Nursing: Concepts,
Process, and Practice.
4. Lynn P. (2011). Taylor’s Handbook of Clinical Nursing Skills. 3rd ed.
5. NANDA International (2012). Nursing diagnosis: Definition and classification 2012-2014.
Oxford: Wiley-Blackwell.
6. Potter, PA. & Perry, A.G. (2009). Potter & Perry’s fundamentals of nursing (7th ed). Sydney:
Mosby

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 Lampiran 2

LEMBAR PENILAIAN PROFESI NERS

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